Revising the essential package of health services through stakeholder alignment, Somalia

Abstract Problem The fragmented health sector in Somalia, burdened by financial challenges and an inadequate regulatory system, struggles to provide equitable essential health services to the entire population. Approach To revise an essential package of health services that stakeholders could support and that aligned with stakeholders’ financial and technical resources, the federal health ministry invited all key stakeholders in 2020 to participate in the revision process of the essential package. The ministry distributed a concept note to invited stakeholders, describing the scope and purpose of the revision process of the essential package. The note also contained a timeline and the expected contribution of each stakeholder. Stakeholders nominated representatives based on their technical expertise and knowledge of the health sector in Somalia. Local setting The health sector in Somalia involves multiple stakeholders, including the health ministry and many development partners. The private sector plays a substantial role in health-care provision. Public spending is an estimated 17% of the total health expenditure. Relevant changes After an 18-month revision process, the health ministry and development partners agreed to prioritize high-impact, cost-effective services and use a progressive realization of the package to improve access and coverage. The implementation strategy considers the health system and operational capacity of service providers, particularly in security-compromised areas. Lessons learnt The approach showed that inclusivity, collaboration and transparency were of importance for a successful revision of the package. These achievements in consensus-building and priority alignment advance the government’s pursuit of equitable and comprehensive health care for all.


Introduction
A prolonged period of conflict in Somalia has led to a fragile health system in the country and persisting challenges in delivering health-care services.For example, the country's universal health coverage (UHC) Service Coverage Index score is 27 out of 100, compared with the regional average of 42.5. 1 The fragmented and often unregulated health services are predominantly provided by the private-for-profit and non-profit sectors.These sectors lack proper coordination or stewardship from the health ministry, which has hindered a successful implementation of the 2009 Essential Package of Health Services.
Recognizing the need for greater coordination among stakeholders to align with national health priorities, the health ministry established an inclusive and participatory coordination structure and a consultative process for revising the country's essential package of health services.This approach aimed to ensure stakeholder buy-in, leading to successful implementation of the revised health service package.Here we describe how this process was conducted.

Local setting
Somalia is experiencing a demographic and epidemiological transition.Maternal, infant and child mortality is decreasing and life expectancy at birth has reached 56.5 years (males: 54.0 years; females: 59.2 years). 2 Although the maternal mortality ratio has decreased from an estimated 732 deaths per 100 000 live births in 2015 to 692 deaths per 100 000 live births in 2020, it remains high. 3,4Similarly, the infant mortality ratio decreased from 91 deaths per 1000 live births in 2014 to 74 deaths per 1000 live births in 2019, yet it remains higher than in many neighbouring countries. 5This transition requires that the Somali health sector is capable of addressing both new and old health problems the population is facing.However, the sector is fragmented and involves multiple stakeholders, including the state health ministries and many development partners.Numerous international and national nongovernmental organizations (NGOs), funded by development partners, provide health services in public facilities.The private sector plays a substantial role in health-care provision, delivering around 60% of health services and 70% of medicines, primarily in urban areas. 6,7The health sector also faces financial challenges.An estimated 17% of total health expenditure is on public spending, while private spending (43%) Provision of health services, Somalia Mohamed A Jama et al.
and donor support (40%) is covering the remaining expenditure. 6

Approach
In February 2017, a new government took office, which ushered in a renewed commitment to take leadership in implementing the existing national health sector strategic plan: a roadmap towards achieving UHC through the primary health care approach.
Aligning with Somalia's ninth national health development plan of 2020 8 and recognizing the need to expand access to essential health services, the government decided to revise the essential package of health services in 2020.The health service package was set as the national framework for organizing, managing and expanding health services.This decision was influenced by improvements in the political and security situation and the anticipation of new funding opportunities from the World Bank.
In January 2020, early in the process of revising the package, the federal health ministry established a three-tier coordination structure and invited key stakeholders to nominate representatives for each level of the coordination structure (Fig. 1).Stakeholders chose their representatives based on technical expertise and knowledge of the health sector in Somalia.The ministry distributed a concept note to invited stakeholders, describing the scope and purpose of the revision process of the essential package.The note also contained a timeline and the expected contribution from stakeholders to the different stages of the planning cycle, such as evidence generation (data collection and analysis), priority setting, implementation strategy, and monitoring and evaluation.
The final coordination structure included representatives from the health ministry at the federal and state levels, finance ministry, civil society organizations, private sector, academia and development partners.During the revision process, the health sector coordination committee, which includes all stakeholders, met on a quarterly basis, while the taskforce for the essential package of health services met every second month.The thematic technical working groups consisting of experts on different health system areas met more frequently.The majority of the meetings took place in a hybrid format, in person and virtually, due to the disruption caused by the coronavirus disease 2019 (COVID-19) pandemic.
The government encouraged all stakeholders to harmonize and align their support with national priorities by using the single treasury account of the government to capture all development assistance for health in the national budget, consistent with the Paris Declaration on Aid Effectiveness of 2005 and the Accra Agenda for Action Plan of 2008, designed to enhance government ownership, efficiency for results and mutual accountability. 9

Relevant changes
Because of the constrained financial resources, and considering the limited delivery capacity of the health system, the taskforce had to make tough choices on what set of interventions in the package should be prioritized and rolled-out first across the five delivery levels of the health-care system of Somalia.The revision process entailed inclusive and in-depth discussions with all stakeholders, culminating in an agreement on the implementation sequence of interventions in the service package.The health ministry and development partners agreed upon the following criteria: (i) services that can address major causes associated with high mortality and morbidity in Somalia and have the most significant impact on health outcomes; (ii) highly costeffective and affordable services within the available resources; (iii) services that can be scaled up to ensure equal access for all populations, regardless of residency.These criteria guided the prioritization and the selection of highimpact, cost-effective services which will be progressively realized to improve access and coverage, by considering the health system and operational capacity of service providers, particularly in security-compromised areas.
After the revision process was finalized in June 2021, the health ministry and development partners started the progressive implementation by using a rational sequencing of health services included in the package.The outcomes of this implementation strategy have informed the long-term organizational transformation embarked upon by the health ministry.This transformation addresses institutional capacity, enhances domestic resources, and improves the availability of human resources, starting with the training of skilled community health workers in a gradual manner.

Lessons learnt
The revision of the Essential Package of Health Services 2020 10 benefitted from broad consultation and agreement with key stakeholders, whose contributions  With a clear recognition of financial limitations and implementation capacity, the government and the development partners embraced a progressive rollout of the package and a pragmatic approach, prioritizing high-impact and cost-effective interventions within the essential package.This implementation strategy facilitated the progressive expansion of essential health services, tailored to address the country's diverse needs, service delivery capacity and resource availability (Box 1).However, the revision process faced challenges due to different positions held by some major stakeholders regarding the prioritization and financing of services, coverage for specific population groups and adopting a delivery model.Given the few available resources, these different positions necessitated an intensive policy dialogue to build consensus on balancing the breadth of coverage and services within the essential package of health services.As a result, the essential package of health services revision process took 18 months to finalize.
The service package, which defined a set of highly cost-effective interventions developed through collaborative endeavours, can strengthen the governance role and institutional capacity of the health ministry.A clear vision and roadmap towards UHC were foundational for the health ministry's leadership.This vision, coupled with strong commitment and advance preparation, set the stage for a major revision involving stakeholders.Additionally, the adoption of the revised essential package as the national framework has been crucial for organizing, managing, and expanding health services, integrating across all programmes.As a result of these efforts, the health ministry has been able to lead and coordinate efforts in advancing health care in the country.
Unifying stakeholders is imperative to overcome the inefficiencies, fragmentation and unpredictability of funding.A collective approach towards funding and resource mobilization can be established by working together, leading to better coordination of funding sources.This collaboration enhances the predictability and sustainability of financing for the health-care system in Somalia, ensuring a stable foundation for the successful implementation of the essential package of health services.
Similarly, addressing the shortage of human resources necessitates stakeholder cooperation.Comprehensive workforce strategies can be devised through joint efforts, encompassing training programmes and incentives to attract and retain skilled healthcare professionals.This collaborative approach will help bridge the healthcare workforce gap, ensuring adequate staffing in health facilities.
The financing and the implementation of a nationally standardized package, which defined a set of health services to be delivered in Somalia under supervision and monitoring by federal and state health ministries, is a major departure from past experience where service providers could choose the parts of the package they preferred.The collective endeavour ensured buyin from stakeholders, which eased the rollout of the revised package, even amidst resource constraints, and has advanced the health-care landscape in Somalia.Astute resource management by the health ministry and careful consideration of the health system's capacity addressed the financial challenges.Focusing on financing from available domestic and external resources, stakeholders have prioritized health services for maternal and child health, communicable diseases, and hypertension and diabetes, which needed improved public accessibility.The dedication to extending equitable access to nomadic and security-compromised areas of the country underscores a solid commitment to enhancing health-care accessibility and equity for all Somalis.■ Provision of health services, Somalia Mohamed A Jama et al.

Fig. 1 .
Fig. 1.Organizational chart of the coordination mechanism revising the essential package of health services, Somalia, 2020